Objective: To explore the feasibility of case-based payment (zero medical expense) for pulmonary tuberculosis (PTB) outpatients through the new rural cooperative medical system (NRCMS) in Hunan province. Materials and Methods: Cross-section and qualitative study were applied. All 131 counties of Hunan province were investigated to identify the current situation of medical security in tuberculosis (TB) patients by questionnaire and telephone interview. Thirty-six staff of nine pilot counties, which already implemented case-based payment were interviewed on their opinions of case-based payment, interviewees were from health bureau, NRCMS sectors and centers for disease control and prevention (CDC) of each county. Results: Outpatient PTB treatment for rural patients was covered by NRCMS in 118 of all 131 counties. Reimbursement models consist of proportional reimbursement, fixed amount reimbursement, and case-based payment. However, the proportion of proportional reimbursement has a range of 30-80%, the payment of amount reimbursement varies from 200 to 1500 RMB Yuan/case. Patients covered by proportional reimbursement and fixed amount reimbursement need to pay the medical expense of 588 Yuan/case and 463 Yuan/case respectively, comparing zero expenditure for patients of case-based payment. NRCMS need input about 17.8 million Yuan more per year to reimburse all rural PTB outpatients’ medical expenses, which only accounted for 0.12% of total NRCMS fund. In those counties, which already implemented case-based payment policy, the number of patients visited CDCs has increased dramatically, follow-up and treatment compliance improved obviously as well. Conclusion: Zero outpatient medical burden for rural TB patients is feasible and realizable through case-based payment under China’s NRCMS.